Top Top 20 20 Selling Herbals Selling Herbals for 2008for 2008- Mass - Mass MarketMarket H HerbalGram erbalGram 2009;82:58-612009;82:58-61

ProductProduct M $M $ % change rank in % change rank in 20072007 1. cranberry1. cranberry 2525 +5.2+5.2 22 2. soy2. soy 2222 -13-13 11 3. garlic 3. garlic 1919 -5.7-5.7 33 4. saw palmetto 4. saw palmetto 1818 +3.2+3.2 55 5. ginkgo5. ginkgo 1515 -2.6-2.6 44 6. echinacea6. echinacea 1515 +4.5+4.5 66 7. milk thistle 7. milk thistle 0909 +7.9+7.9 88 8. St. John’s Wort8. St. John’s Wort 0808 +1.5+1.5 1010 9. ginseng 9. ginseng 0808 -3.7-3.7 99 10. black cohosh10. black cohosh 0808 - 7.1- 7.1 77 11. green tea 11. green tea 0606 +5.3+5.3 1111 12. evening primrose oil12. evening primrose oil 0404 - 7.1- 7.1 1212 13. valerian13. valerian 0303 +11+11 1313 14. horny goat weed14. horny goat weed 0202 +8.7+8.7 1414

Top Top 20 20 Selling Herbals Selling Herbals for 2008for 2008- Mass - Mass MarketMarket H HerbalGram erbalGram 2009;82:58-612009;82:58-61

ProductProduct M $M $ % change rank in % change rank in 20072007 15. grape seed15. grape seed 0202 +7+7 1616 16. elderberry16. elderberry 0202 +124+124 nonenone 17. bilberry17. bilberry 0202 +1.9+1.9 1515 18. ginger18. ginger 0101 +42+42 2020 19. horse chestnut seed19. horse chestnut seed 0.80.8 -19-19 1919 20. yohimbe20. yohimbe 0.70.7 -43-43 1717

Total Mass Market sales (all herbs)Total Mass Market sales (all herbs) 289289 +7.2+7.2

Total all channels sales (estimated) 4,800Total all channels sales (estimated) 4,800 +0.9+0.9

The above figures include only sales from food stores, drug stores, The above figures include only sales from food stores, drug stores, and mass market retailers but with Wal-Mart figures not included. It and mass market retailers but with Wal-Mart figures not included. It does not include warehouse buying clubs (Costco), convenience does not include warehouse buying clubs (Costco), convenience stores, natural foods stores, multilevel marketers, health stores, natural foods stores, multilevel marketers, health professional sales, mail order or internet sales.professional sales, mail order or internet sales.

Grape Seed ExtractGrape Seed Extract BotanyBotany

Seeds from Vitis viniferaSeeds from Vitis vinifera HistoryHistory

Relatively recent use as an antioxidantRelatively recent use as an antioxidant ChemistryChemistry

seeds contain olygemeric seeds contain olygemeric proanthocyanidins (OPC)proanthocyanidins (OPC)

OPC s are oligomeric or polymeric flavonoid OPC s are oligomeric or polymeric flavonoid like polyphenolic compoundslike polyphenolic compounds

OPC s have strong antioxidant and free OPC s have strong antioxidant and free radical scavanging activitiesradical scavanging activities

OPC s are also high in marine pine bark OPC s are also high in marine pine bark (pycnogenol) and green tea(pycnogenol) and green tea

Pharmacology

•In vitro will prevent destruction of elastin, collagen and hyaluronic acid

•In animal models will reduce capillary permeability and decrease swelling and inflammation

•Action due to the ability of OPC s to block free radical damage and otherwise protect against oxidative damage

Uses

•Treatment of varicose veins and chronic venous insufficiency

•Reduce swelling due to surgery or injury

•Treat and prevent macular degeneration

•To reduce the risk for cancer and heart disease

•Treat diabetic retinopathy and neuropathy

•other

Evidence

•Varicose veins

•Reasonable evidence based on placebo controlled trials. Trials published in French and Italian thus not readily evaluated by all

•Reduce pain and swelling due to injury/surgery

•Three controlled studies (in French)

•Vision - one study

•Heart Disease – some evidence for potential

Other – limited evidence from animal or in vitro studies; may lower cholesterol in combination with chromium

LDL oxidation; N=15 with CAD; grape juice x14d; Stein et al. Circulation 1999;100:1050-1055.

Flow mediated vasodilation; N=15 with CAD; grape juice x14d; Stein et al. Circulation 1999;100:1050-1055.

Safety

Considered nontoxic

Interactions

OPCs have antiplatelet adhesion properties so that an anticoagulant effect could be noted at higher doses; avoid concurrent use with warfarin and other anticoagulants

Products

Grape seed extract products contain 100mg of extract per capsule. Dose: 100mg TID

Grape Seed ExtractGrape Seed Extract SummarySummary

EfficacyEfficacy: probably effective for varicose : probably effective for varicose veins and venous insufficiency. May veins and venous insufficiency. May help vision and macular degeneration. help vision and macular degeneration. Other uses need more work.Other uses need more work.

SafetySafety: good: good Drug interactionsDrug interactions: careful with : careful with

anticoagulantsanticoagulants Product selectionProduct selection: ? Most are not : ? Most are not

standardized to OPCsstandardized to OPCs DoseDose: 100mg TID: 100mg TID Questions remainingQuestions remaining include include

Will grape seed extract help in vascular Will grape seed extract help in vascular diseases other than varicose veins? What diseases other than varicose veins? What about coronary disease?about coronary disease?

ElderberryElderberry

Botany: Sambucus sp. , usually S. nigerBotany: Sambucus sp. , usually S. niger Chemistry: anthocyanadin glycosides, Chemistry: anthocyanadin glycosides,

e.g. cyanidin-3-glucosidee.g. cyanidin-3-glucoside Pharmacology: elderberry Pharmacology: elderberry

anthocyanidins inhibit influenza viruses anthocyanidins inhibit influenza viruses in vitro (also H1N1) and have immune in vitro (also H1N1) and have immune stimulation and antiinflammatory stimulation and antiinflammatory propertiesproperties

ElderberryElderberry Uses: influenza, sciatica, immune stimulant, asthma Uses: influenza, sciatica, immune stimulant, asthma

and other usesand other uses Efficacy: shown to have some activity in relieving Efficacy: shown to have some activity in relieving

symptoms of influenzasymptoms of influenza

Zakay-Rones et al. J Altern Complement Med Zakay-Rones et al. J Altern Complement Med 1995;1:361-9. (Israel study against influenza B). 2-3d vs 1995;1:361-9. (Israel study against influenza B). 2-3d vs 6d end of symptoms, n=27)6d end of symptoms, n=27)

•Zakay-Rones et al. J Int Med Res 2004;32:132-40. (Influenza A and B)N=60, 15ml of syrup QID x 5d starting within 48h of onset. Study done in Oslo Norway. Difference in time to end of symptoms was 4d shorter in elderberry vs placebo (p<0.001). Reduced use of pain and other cold meds in elderberry group.

•Kong F. Online Journal of Pharmacology and Pharmacokinetics 2009;5:32-43. (lozenge) n=64 relief of symptoms faster compared to placebo

ElderberryElderberry Safety: seems OK but leaves and Safety: seems OK but leaves and

unripe berries contain cyanogenic unripe berries contain cyanogenic glycosides that can release HCNglycosides that can release HCN

SummarySummary EvidenceEvidence:: A few human studies support use to A few human studies support use to

decrease influenza symptomsdecrease influenza symptoms SafetySafety: a quality product is recommended due to : a quality product is recommended due to

risk of cyanide poisoning if contaminated with risk of cyanide poisoning if contaminated with leaves or unripe fruit.leaves or unripe fruit.

Drug InteractionsDrug Interactions: possibly not with : possibly not with immunosuppressantsimmunosuppressants

Products: Products: syrupsyrup GWE:GWE:.worth a try to relieve flu symptoms. Start .worth a try to relieve flu symptoms. Start

ASAP and take for 5d. Nature’s Way Sambucus ASAP and take for 5d. Nature’s Way Sambucus product is suggestedproduct is suggested

Bilberry

•Botany- extract of the fruit of the “European Blueberry” which has a white inside. Vaccinium myrtillus. Common blueberries are other Vaccinium sp.

•History-used by English pilots in WWII to improve night vision

•Chemistry-contains anthocyanosides (glycosides of anthocyanidins); these like OPCs (see grape seed extract) are powerful antioxidants

•Pharmacology- antioxidant and free radical scavanging activities with maybe special action in the eye

•Use-poor night vision, cataracts,macular degeneration,diabetic retinopathy

•Evidence-

•conflicting small studies. More work needs to be done; study by the US Navy showed no benefit in night vision (Muth et al. Alter Med Rev 2000;5:164-173) in a small placebo controlled study (n=13) in men with normal vision

•Retinopathy. Diabetic and hypertensive retinopathy improvement in 2 small studies.

•Safety-OK Interactions-none

•Products-look for extracts standardized to 25% anthocyanosides; 100mg qd or BID

•Summary-safe but unproven product for vision problems

Yohimbe

•Botany:

•W. African tree (Pausinystalia yohimbe)

•bark used

•Chemistry:

•about 6% alkaloids

•2-4% yohimbine (Rx only, 5.4mg TID)

•Pharmacology:

•alpha adrenergic receptor blocker

•increase excitability in sacral region of spinal cord

•MAOIvasodilation

Yohimbe

•Adverse

•CNS stimulation (lower doses)

•hypertension (lower doses), insomnia

•activation of psychoses

•Hypotension (higher doses)

•Cardiac depression (higher doses)

•Herbal/Drug interactions

•MAOI

•additive problems with adrenergic and other MAOI

Ernst and Pittler, J. Urology 159:433-436,1998

Yohimbine-Bottom line

•Adverse effects could be significant but warnings in the literature may be exaggerated

•Reasonable evidence for some improvement in ED and sexual dysfunction associated with SSRI therapy

•Studies needed to compare with Viagra etc

•Rx drug, usually 15-30mg/d used; avoid >30mg/d

Yohimbe-Bottom line

•May work but adverse effects exist and other drugs are probably better

•Quality control problems

•Most dietary supplement products have subtherapeutic amounts of yohimbine

•If 6% yohimbine, then 250-500mg/d would be the dose

Yohimbine: an alkyloid

Horse Chestnut

•Botany Aesculus hippocastanum

•History Long used but in recent years seed extract has been tested in human studies

•Chemistry the triterpine glycoside escin is thought to be the active

•Pharmacology Escin inhibits hyaluronidase and elastase which are involved in increased capillary permeability.

•Use horse chestnut seed and leaf are used for the treatment of varicose veins, hemorrhoids, and phlebitis. Horse chestnut seed is used for diarrhea, fever, and enlarged prostate. Seed extract used for venous insufficiency and varicose veins

Diehm et al. Lancet 1996;347:292-294; n=240; extract containing 50mg escin BID

Horse ChestnutHorse Chestnut

Horse chestnut seed extract for chronic venous Horse chestnut seed extract for chronic venous insufficiency.insufficiency.

Pittler MH, Ernst E MH, Ernst E Cochrane Database Syst Rev. 2006 Cochrane Database Syst Rev. 2006 Jan 25;(1):CD003230.Jan 25;(1):CD003230.

Authors' conclusionsAuthors' conclusions ““The evidence presented implies that HCSE is an The evidence presented implies that HCSE is an

efficacious and safe short-term treatment for CVI. efficacious and safe short-term treatment for CVI. However, several caveats exist and more rigorous RCTs However, several caveats exist and more rigorous RCTs are required to confirm the efficacy of this treatment are required to confirm the efficacy of this treatment option.”option.”

Horse ChestnutHorse Chestnut

EvidenceEvidence:: human studies support use of the human studies support use of the seed extract in varicose veinsseed extract in varicose veins

SafetySafety:the raw seed contains the toxic :the raw seed contains the toxic esculin which can cause bleeding and other esculin which can cause bleeding and other adverse events. The extract does not and is adverse events. The extract does not and is safe.safe.

Drug InteractionsDrug Interactions: anticoagulants: anticoagulants Products:Products:seed extract onlyseed extract only Summary:Summary:reasonable evidence for varicose reasonable evidence for varicose

veins and is recommended. Use seed veins and is recommended. Use seed extract standardized to 16-24% escin extract standardized to 16-24% escin (aescin).(aescin).

GingerGinger Zingiber officinaleZingiber officinale History-History-long used for food and medicinelong used for food and medicine PharmacologyPharmacology

digestive aiddigestive aid flavorflavor nausea and vomiting treatment-effect is nausea and vomiting treatment-effect is

on the stomach and less on the CNSon the stomach and less on the CNS For painFor pain

ChemistryChemistry volatile compoundsvolatile compounds non volatile compoundsnon volatile compounds

gingerolgingerol shogaolshogaol

GingerGingerEfficacy StudiesEfficacy Studies

motion sicknessmotion sicknessmost studies “in the field” show most studies “in the field” show some benefit but those in a some benefit but those in a spinning chair are equivocalspinning chair are equivocal

Nausea and vomiting of Nausea and vomiting of pregnancypregnancy

Seems helpful with little riskSeems helpful with little riskpost operative nausea and post operative nausea and vomitingvomiting

most studies, but not, all support most studies, but not, all support benefitbenefit

Grontved A, Brask T, Kambskard J, Hentzer E. Ginger root against seasickness: a controlled trial on the open sea. Acta Otolaryngol 1998;105:45-9. n=80

Ginger for Nausea of Pregnancy

0

0.5

1

1.5

2

2.5

3

3.5

placebo,n=35 ginger,n=32

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Pregnancy nausea scores (difference from baseline at day 4); 1g ginger/d; n=67; p=.005

From Vutyavanich et al. Obstet Gynecol 2001;97:577-582.

N=291 <16 weeks pregnant; assessed at 7, 14, 21dSmith et al. Obstet Gynecol. 2004 Apr;103(4):639-45

Chaiyakunapruk et al. Am J Obstet Gynecol. 2006;194:95-9

Postoperative nausea and vomiting

Other uses:

•Pain/osteoarthritis – possible mild effects based on a few studies but ginger takes weeks to see benefit

•Nausea asociated with cancer chemotherapy-studies are not in agreement

Summary for GingerSummary for Ginger

EfficacyEfficacy: : possibly worthwhile in preventing possibly worthwhile in preventing motion sickness; worthwhile in treating and motion sickness; worthwhile in treating and preventing nausea of pregnancy; possibly preventing nausea of pregnancy; possibly worthwhile in treating postop nauseaworthwhile in treating postop nausea

SafetySafety: good; abdominal discomfort for : good; abdominal discomfort for somesome

Drug interactionsDrug interactions: caution with warfarin: caution with warfarin Product selectionProduct selection: ?: ? DoseDose: for pregnancy, use 250mg QID (or : for pregnancy, use 250mg QID (or

more); to prevent motion sickness use 1g more); to prevent motion sickness use 1g 1-4h before travel and 250mg QID during; 1-4h before travel and 250mg QID during; to prevent postop nausea use 1g 1h prior to prevent postop nausea use 1g 1h prior to anesthesiato anesthesia

Questions remaining:Questions remaining: How much benefit and how best usedHow much benefit and how best used